Avoid Stress Fractures: What Every Runner Needs to Know About Bone Health
Stress fractures are a common overuse injury among runners, as a result of repetitive stress on bones that exceeds their capacity to recover. Understanding the causes of bone stress injuries, how to prevent them and what to do in the case of suspecting a bone stress injury is crucial in prevention and early management.
Understanding Stress Fractures
A stress fracture is a small crack in a bone caused by repetitive force, often from overuse, such as repeated loading/jumping or running. They commonly occur in weight-bearing bones, including the tibia (shin bone), metatarsals (bones of the foot), and femur (thigh bone). Early signs include localised pain that worsens with activity and subsides with rest. A dull, aching pain at night can also be indicative of a stress fracture. If left unaddressed, these can progress to complete fractures, which then require prolonged recovery.
Key Risk Factors
- Training Errors
Sudden increases in training volume or intensity without adequate rest can overload bones. Adhering to an appropriately graded plan with appropriate de-load is vital. - Biomechanical Issues
Abnormal gait patterns, such as over rotating through the foot or poor footwear can lead to uneven stress distribution on bones. - Nutritional Deficiencies
Inadequate intake of calcium and vitamin D can impair bone remodelling and strength. - Relative Energy Deficiency in Sport (RED-S)
A syndrome resulting from insufficient energy intake relative to expenditure, RED-S affects bone health, menstrual function and overall performance. It can also be common in post partum women, when many people experience a negative energy balance.
Prevention Strategies
- Structured Training Plans
Ensuring that training has built-in rest days and de-load weeks help to prevent overuse injuries. - Strength and Conditioning
Incorporate two sessions weekly of strength or resistance training, emphasising loading on all the major muscle groups. - Nutritional Support
Ensuring adequate calorie intake and balanced nutrition to support bone health and energy availability. - Monitoring Menstrual Health
For female athletes in this phase of life, regular menstrual cycles are indicators of hormonal balance and bone health. Absence of menstruation can be an indicator of bodily stress and directly impacts bone health.
Rehabilitation Protocols
If a stress fracture has developed, early intervention is critical and most often involves a multidisciplinary approach.
- Activity Modification
Ceasing high-impact activities to allow bone healing. - Physiotherapy
Tailored exercises to maintain cardiovascular fitness (whilst off-loading bones appropriately) and to address underlying biomechanical issues. - Podiatrist/Dietician
Depending on the causal factors, podiatry or dietetic review may be considered.
- Gradual Return to Exercise/Running
A specific return to exercise program should be implemented to ensure a low risk of the injury returning.
Key Takeaway
Stress fractures, while common among runners and exercisers, are preventable and manageable with informed care. Be mindful of increasing training load too quickly and ensure proper nutritional intake, relative to your body’s demands. If you’re noticing dull pain after activity that is hard to pinpoint and is worse at night, book with one of our Physiotherapists to assist in diagnosis and management (before it becomes a bigger issue!).
References
Bennell, K. L., Malcolm, S. A., Thomas, S. A., Wark, J. D., & Brukner, P. D. (1996). The incidence and distribution of stress fractures in competitive track and field athletes: A twelve-month prospective study. The American Journal of Sports Medicine, 24(2), 211–217. https://doi.org/10.1177/036354659602400217
Milgrom, C., Finestone, A., & Shlamkovitch, N. (2015). Stress fractures in athletes: Diagnosis and management. Sports Medicine, 45(3), 245–256. https://doi.org/10.1007/s40279-014-0275-9
Mountjoy, M., Sundgot-Borgen, J., Burke, L., Ackerman, K. E., Blauwet, C., Constantini, N., Lebrun, C., Lundy, B., Melin, A., Meyer, N., Sherman, R., Steffen, K., Budgett, R., & Ljungqvist, A. (2018). IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. British Journal of Sports Medicine, 52(11), 687–697. https://doi.org/10.1136/bjsports-2018-099193
Napier, C., Willy, R. W., & Nigg, B. M. (2022). Biomechanics associated with tibial stress fractures in runners: A systematic review and meta-analysis. Journal of Sport and Health Science, 11(5), 519–529. https://doi.org/10.1016/j.jshs.2021.08.004
Nattiv, A., Kennedy, G., Barrack, M. T., Abdelkerim, A., Goolsby, M. A., Arends, J. C., & Matheson, G. O. (2013). Correlation of stress fracture risk factors with bone mineral density in female athletes: A cross-sectional study. Journal of Sports Science and Medicine, 12(1), 180–189
Neal, B. S., Griffiths, I. B., Dowling, G. J., & Murley, G. S. (2019). Risk factors for lower extremity stress fractures in runners: A systematic review. British Journal of Sports Medicine, 53(23), 1530–1538. https://doi.org/10.1136/bjsports-2018-099784
Wright, A. A., Taylor, J. B., Ford, K. R., Dischiavi, S. L., Smoliga, J. M., & Hegedus, E. J. (2015). Risk factors associated with lower extremity stress fractures in runners: A systematic review. British Journal of Sports Medicine, 49(23), 1517–1523. https://doi.org/10.1136/bjsports-2015-094980
